Week 3; High Risk OB Flashcards
Conditions that complicate pregnancy can be divided into 2 categories:
- Those related to pregnancy and not seen at other times
- Those that could occur at anytime but occur concurrently with pregnancy
Most common conditions that cause pregnancy complications
Abortion, ectopic Pregnancy, hydatidiform mole, placenta previa, abruptio placenta, DIC, hyperemesis gravidum, preeclampsia/eclampsia, HTN, gestational diabetes, cardiac Disease, infections
Abortion definition
Loss of Pregnancy before the fetus is viable or capable of living outside the uterus. Considered a hemorrhagic condition of early pregnancy
Spontaneous abortion
Most common cause is congenital abnormality, pregnancy is less than 20 weeks
Threatened abortion
Bleeding during 1st half of pregnancy
Inevitable abortion
Cannot be stopped
Incomplete abortion
Sometimes called partial; all tissue contents have not been expelled
Complete abortion
All of the products (tissue) of conception leave the body.
Missed abortion
Fetus dies but is retained in the uterus
Recurrent spontaneous abortion
3 or more spontaneous abortions, chromosomal or genetic abnormality or anomaly
First sign of possible abortion
vaginal bleeding, which is common during early pregnancy.
Therapeutic management for abortion
- Monitor BP
- Assess for signs of shock (hypovolemia)
- Count or weight pads
- Notify MD/Nurse-Midwife
- Ultrasound
- No evidence to limit activity, but possibly limit
sexual activity - Psychological Support
Hypovolemic shock
Due to blood or fluid loss
S/S of hypovolemic shock:
Low BP, rapid pulse
Weakness
Fatigue
Dizziness, fainting
Skin cool and clammy
S/S of hypovolemia: progressive to emergency status
Impaired perfusion to organs, anuria, loss of reflexes, change in LOC
Abortion treatment
Control fluid loss, administer IV fluids or blood, administer oxygen, monitor respiratory effort, mechanical ventilation may be required, assess LOC, monitor labs, administer medications
Ectopic pregnancy
Implantation of a fertilized ovum outside of
uterine cavity; 97% occur in fallopian tube
Ectopic pregnancy risk factors
Common factor is scarring, hx of previous ectopic pregnancies, delayed or premature ovulation, IUDs associated
Clinical manifestations of ectopic pregnancy:
Missed period, positive pregnancy test, abdominal pain, spotting
Ectopic pregnancy: If tube tears open and embryo expelled into pelvic cavity, what follows?
Profuse abdominal hemorrhaging, radiating pain under scapula may indicate bleeding into
abdomen, hypovolemic shock
When ectopic pregnancy ruptures, what intervention is required?
Surgical
Assessment & treatment for the patient with ectopic pregnancy
Monitor for signs that suggest rupture or bleeding
Treatment: IV fluids, pain control, methotrexate administration – chemo agent. Stops pregnancy and causes hormones to return to normal. Psychological Support
Gestational trophoblastic disease, AKA:
Hydatidiform mole, invasive mole, or choriocarcinoma
Gestational trophoblastic disease
Trophoblasts develop abnormally. Characterized by proliferation and edema of the chorionic villi and form grape-like clusters of tissue. Placenta does not develop normally and I fetus present – fatal chromosome effect
Trophoblasts
peripheral cells that attach the fertilized ovum to the uterine wall
Gestational trophoblastic disease incidence and risk factors
Incidence in US and Europe – 1 in every 1000-1500
pregnancies
Higher in youngest and oldest
Asians have higher incidence
Gestational trophoblastic disease s/s:
-Higher levels of beta-hCG than expected for
gestation
-“Snowstorm” ultrasound pattern
-Absence of fetal sac and presences of vesicles
-Uterus larger than expected
-Bleeding which varies from dark brown spotting to
profuse hemorrhage
Two phases of treatment for gestational trophoblastic disease
- Assist with medical management – evacuation procedure
- Continuous follow up to detect malignant changes of any remaining trophoblastic tissue
Nursing care for gestational trophoblastic disease
Monitor bleeding, emotional support – women experience similar emotions to those who have experienced any other type of pregnancy loss, patient Anxious about follow up
Nurses role, regardless of the cause of early
antepartum bleeding –
-Monitoring the condition of the patient (VS, bleeding)
-Pain Control
-IV fluids
-Collaborating with physician to provide treatment
Hemorrhagic conditions of late pregnancy: placenta previa
Implantation of the placenta in the
lower uterus
Placenta previa: Three classifications:
Total, partial, and marginal
Placenta previa example
Placenta previa incidence and risk factors
Incidence is 1 in 200 births
More common in older women, multiparas, previous C-sections or uterine surgery
Increased risk: asians, smokers, and cocaine use
Classic sign of placenta previa:
Sudden onset of painless uterine bleeding in the last half of pregnancy
Nursing considerations with placenta previa
Until the location and position of the placement are verified by ultrasound – no manual vaginal exam should be performed.
Oxytocin postponed to prevent strong contractions which could result in sudden placental separation and rapid hemorrhage
Placenta previa interventions
-Based on condition of the mother and fetus
-Assess amount of blood
-Electronic fetal monitoring
-If home care, nurses help patient to understand
-Assessing color and amount of vaginal discharge or bleeding
-Assessing fetal activity (kick counts daily)
-Assessing uterine activity at prescribed intervals
-Refraining from sexual intercourse to prevent disruption of placenta
Inpatient care for placenta previa
-Goal is greater fetal maturity
-Supportive nursing care
-Patient may be on bedrest and confined to bed
-Periodic fetal monitoring
-Scheduled delivery if fetus 36 weeks or more
-Delivery if serious hemorrhage, impact to fetus, prepare for C-section
-IV, admin of preop antibiotics, anesthesia, foley inserted, fetal monitor, neonatology team ready
Abruptio placentae
Separation of a normally implanted placenta before the fetus is born. Bleeding and formation of clot on the maternal side of the placenta; as clot expands, further separation occurs. Bleeding may be concealed
Abruptio placentae incidence
Occurs in approx. 0.5% -1% of pregnancies
Abruptio placentae 3 types:
Marginal; external bleeding
Partial abruption; internal bleeding
Complete abruption; concealed bleeding
Abruptio placentae s/s:
-Bleeding – vaginally or concealed
-Uterine tenderness
-Uterine irritability
-Abdominal or low back pain
-“Board-like” abdomen
-Port wine colored amniotic fluid
-Nonreassuring FHR or fetal death
-Signs of hypovolemic shock
Abruptio placentae nursing care
-Hospitalization immediately
I-f fetus under 34 weeks – conservative care
-Immediate delivery if fetus compromised
Assess for signs of concealed hemorrhage with abruptio placentae
-Assess for signs of concealed hemorrhage
-Increase in fundal height
-Board-like abdomen
-High uterine baseline tone on monitoring strip
-Persistent abdominal pain
-Systemic signs of hemorrhage (tachycardia, falling BP, falling urine output, restlessness)
-Slight or absent vaginal bleeding
DIC
Life-threatening defect in coagulation; may occur with pregnancy complications such as abruptio placentae or hypertension. Inappropriate coagulation occurring in microcirculation. Tiny clots form in the tiny blood vessels, blocking blood flow to organs causing ischemia. Clotting mechanisms are initiated inappropriately and circulating blood unable to clot
DIC nursing considerations
-Nurse should assess for bleeding from IV insertion sites or nosebleeds, gums, and from site of placental attachment during postpartum period and monitor VS.
-Labs: Fibrinogen and platelets usually decreased, PT prolonged
-Priority in DIC is to correct the cause
-Prepare for Blood Transfusion to maintain circulating volume and transport oxygen to cells
-I&O
-Get accurate output including blood soaked materials (weights) - 1 gram is equal to 1 ml of blood
-Apply Oxygen
Hyperemesis gravidarum
Persistent, uncontrollable vomiting that begins in first weeks and continues throughout. Not the same as morning sickness – which is self-limited and causes non-serious effects. Etiology is unknown
Therapeutic management of hyperemesis gravidarum
Diphenhydramine (Benadryl)
Histamine-receptor antagonists (Pepcid/Zantac)
Gastric acid inhibitors (Nexium/Prilosec)
Metoclopramide (Reglan)
Pyridoxine/doxylamine (Diclegis)
Caring for the patient with hyperemesis gravidarum
Meds, ongoing assessment, IV fluids, assess for signs of dehydration, I&O, monitor labs, weight, eat small meals every 1-2 hours, and emotional support.
-Weight loss and ketones indicate fat stores and protein are being metabolized
-As a rule of thumb, normal urinary output is about 1 ml/kg/hr
Hypertensive disorders of pregnancy
Gestational hypertension, preeclampsia-eclampsia, chronic hypertension, chronic hypertension with superimposed preeclampsia
Preeclampsia
A hypertensive disorder of pregnancy characterized by new onset hypertension (after 20 weeks gestation and multisystem involvement - proteinuria, organ involvement or injury (liver, brain, kidneys)
BP ≥140 mm HG systolic or ≥90 mm Hg diastolic
Eclampsia –
Form of hypertension of pregnancy complicate by generalized (grand mal) seizures. Woman’s blood volume severely reduced in eclampsia, increasing risk for poor placental perfusion.
Preeclampsia incidence and risk factor
5-10% of all pregnancies
Risk factors: First pregnancy, 35 or older, African-American descent, men who fathered pre-eclamptic pregnancies in past, obesity, diabetes, SLE, multiple fetuses, history of preeclampsia
Note: African American women experience a three-fold higher risk of mortality from complications 38.9 per 100,000 compared to 12.0 per 100,000.
Preeclampsia patho
Generalized vasoconstriction and vasospasm resulting in multiple system organ failure. Underlying cause of vasospasm is unknown. Placenta exam reveals abnormal development in maternal spiral arteries leading to decreased perfusion and oxygenation. Other hypothesis include dysregulation of maternal immune response to fetal and placenta antigens.
Peripheral vascular resistance increases and may be linked to angiotensin II results in further vasospasm and retention of sodium and water.
Vasospasm decreases diameter of blood vessels which results in endothelial cell damage and increase capillary permeability, which impedes blood flow and elevates BP.
Preeclampsia cure
Only known cure is delivery
Preeclampsia is dangerous for woman and fetus for 2 reasons:
- It can develop and worsen rapidly
- Earliest symptoms are often not noticed by the woman
Preeclampsia prevention:
Prenatal Care, monitoring BP and weight gain, no consensus on dietary restrictions, monitor for edema
Preeclampsia is a leading cause of maternal and perinatal morbidity and mortality globally and __ can be one of the cardinal features of this disease.
proteinuria
S/S/assessment of the patient with preeclampsia
Elevated BP, headache, drowsiness
Check deep tendon reflexes for hyperreflexia; indicates cerebral irritability.
Clonus – rapidly alternating muscle contraction and relaxation may occur when reflexes are hyperactive - report to provider.
C/o visual changes – get full explanation, blurry, double, flashes?
Ask about headache, changes in LOC
Edema – note any pitting edema
Numbness or tingling in hands and feet
Decreased urinary output
Epigastric pain or upset stomach
Management of the patient with preeclampsia
Home Care, activity restrictions with rest, blood pressure monitoring, weight monitoring, urinalysis, fetal assessment, diet – ample protein and calories, salt or fluid restriction not as common anymore but should watch sodium
Severe preeclampsia
-Systolic BP of 160 or greater or diastolic greater than 110
-Thrombocytopenia
-Impaired LFTs
-Progressive renal insufficiency
-Pulmonary edema
-Cerebral or visual disturbances – increased neuro changes due to cerebral edema
-Oliguria of less than 500 ml in 24 hours
HELLP Syndrome – subset of severe preeclampsia
Hemolysis
Elevated Liver enzymes
Low Platelets
Management of severe preeclampsia
-Requires hospitalization
-Antepartum Management – increase blood flow and oxygenation and to prevent seizures
-Magnesium sulfate (most commonly used)
-Antihypertensive medication
-Anticonvulsant medications
Magnesium sulfate
Action – depresses CNS irritability and relaxes smooth muscle, decreases intensity of contractions
Indications: prevention and control of seizures, prevention of contractions in preterm labor, neuroprotection of preterm fetus
Dosage and route – usually IV, IM but painful
Onset of action immediate (IM one hour)
Contraindications and precautions – myocardial damage, Heart block
Reactions – OD possible, flushing, sweating, hypotension, CNS depression, respiratory depression
Antidote: Calcium gluconate
Signs of magnesium toxicity
-Respiratory depression (fewer than 12 per min)
-Chest pain
-Decreasing maternal pulse ox (less than 95% during pregnancy, less than 92% postpartum)
-Absence of DTRs or significantly decreased
-Blurred vision
-Altered sensorium
-Oliguria
-Hypotension
-Serum magnesium greater than 8mg/dl
-Respiratory and Cardiac arrest
Management of severe preeclampsia; Interventions for Seizures
-Monitor for impending seizure
-Decrease stimuli, move calmly, keep sound low
-Place on “seizure precautions”
-Prevent seizure related injury – padded side rails.
-Left side lying position
-O2 and suction equipment ready
-Crash cart ready
-Prepare for emergency delivery
-Magnesium sulfate with calcium gluconate (antidote) ready
-Maintain patent airway after seizure and suction if needed, administer oxygen by non-rebreather face mask at 10L/min
-Notify MD – this is an emergency and can be related to cerebral hemorrhage, placental abruption, fetal hypoxia and death
-Administer medications
Eclampsia therapeutic management
-Monitor for ruptured membranes, signs of labor, or abruptio placentae
-Because of reduced blood volume, fluid shifts from intravascular space to interstitial space including lungs, causing pulmonary edema. Check lungs!
-Renal blood flow can be impaired
-Monitor BP
-Pulse Ox
-Administer Lasix if pulmonary edema develops
-Oxygen nonrebreather mask at 10 L/min
-Digoxin may be needed to strengthen contraction of the heart if circulatory failure results
-Frequent assessments, at least hourly
-Postictal – keep on side to prevent aspiration and improve fetal circulation
-Side rails raised and padded
-DIC is possible
Chronic HTN dx:
Evidence suggests that hypertension preceded the pregnancy. When a woman is hypertensive before 20 weeks of gestation
Rh incompatibility
Rhesus disease is a condition where antibodies in a pregnant woman’s blood destroy her baby’s blood cells. Also known as hemolytic disease of the fetus and newborn (HDFN). Two conditions must exist: Mother is Rh-negative and fetus is Rh-positive. If infant is Rh negative, Rh antibody formation does not occur and RhoGAM is not necessary.
RHOGAM - \
Rh immune globulin (RhIg) prevents development of Rh antibodies that would result in destruction of fetal erythrocytes in subsequent pregnancies. Can also be given in first trimester. If physician determines that the mother has already developed antibodies against the fetus baby, pregnancy will be closely monitored.
Hemolytic disease in newborns:
Causes issues including encephalopathy, neurological disease and rapid production of erythroblasts which cannot carry blood in the neonate. Entire syndrome is called erythroblastosis fetalis.
Postpartum management of RH incompatibility
making sure mother gets injection within 72 hours, monitoring newborn
Diabetes mellitus
Complex disorder of carbohydrate metabolism caused by a partial or complete lack of insulin secretion by the beta cells of the pancreas. Without insulin, glucose accumulates in the blood (hyperglycemia). Classic symptoms of diabetes include polydipsia, polyuria, and polyphagia
DM effects on early pregnancy
Little change in maternal metabolic needs. Insulin release in response to serum glucose levels accelerates. May experience hypoglycemia
DM effects d/t hormones
Fetal growth accelerates, causing a rise in placental hormone levels. Hormones create resistance to insulin.
DM effects on birth
Maintaining normal maternal glucose levels essential during birth to reduce neonatal hypoglycemia
DM effects on postpartum period
Need for additional insulin, breastfeeding encouraged. The added calorie intake by the mother helps lower the amount of insulin needed in women with types 1 and 2 diabetes mellitus. The woman with gestational diabetes mellitus (GDM) usually needs no insulin after birth.
Gestational (GDM)
Onset of glucose intolerance during pregnancy
GDM incidences
Approximately 9.2% of all pregnancies are affected by GDM. About half of women with GDM will develop Type 2 DM later in life.
DM maternal effects during first trimester
Hypoglycemia, hyperglycemia, ketosis. Increased incidence of spontaneous abortion or major fetal malformations. Preeclampsia more likely to develop if preexisting diabetes, ketoacidosis, premature rupture of the membranes (PROM), and shoulder dystocia
Fetal effects d/t DM
Congenital malformation, variations in fetal size, small for gestational age (SGA), intrauterine growth restriction (IUGR)
Neonatal effects d/t DM
Hypoglycemia, hypocalcemia, hyperbilirubinemia, respiratory distress syndrome
DM maternal assessment
History, onset and management of diabetic condition, may need insulin to control (injection; no oral agent), physical exam, baseline electrocardiogram (ECG), ophthalmology referral, weight and blood pressure (BP), laboratory tests such as 24 hour urine and hemoglobin A1c (HbA1c)
Monitoring fetus in mom who has DM:
Should begin early with preexisting diabetes; testing for anomalies, frequent ultrasound, fetal echocardiogram at 20 to 22 weeks, maternal assessment of fetal movement, and doppler velocimetry
DM therapeutic management
Maintain normal blood glucose levels, facilitate the birth of a healthy baby, avoid accelerated impairment of blood vessels and other major organs
Preconception care: diet, self-monitoring of glucose, insulin therapy
During labor maintenance of tight maternal glucose control is desirable to reduce neonatal hypoglycemia
Gestational diabetes risk factors
Overweight, maternal age older than 25 years, previous birth outcome often associated with GDM, GDM in previous pregnancy, hx of abnormal glucose tolerance, hx of diabetes in a close relative, member of a high-risk ethnic group, hx of prediabetes, hx of polycystic ovary syndrome
GDM screening; 1 hour test
Glucose challenge test (24 to 28 weeks)
50 g of oral glucose solution
If abnormal (>140 mg/dL)
GDM screening; 3 hour oral glucose tolerance test
Oral glucose tolerance test (OGTT)
Fasting, 95 mg/dL
1 hour,180 mg/dL
2 hours,155 mg/dL
3 hours,140 mg/dL
GDM nursing considerations
Increase effective communication.
Provide opportunities for control.
Provide normal pregnancy care.
Cardiac disease and pregnancy
Heart disease complicates about 1% to 4% of pregnancies.
It remains a significant cause of maternal mortality.
The two major categories of heart disease are acquired heart disease and congenital heart disease.
Changes in pregnancy cause added stress and burden on an already compromised hires
May result in ischemic events or CHF
Cardiac Disease: Intrapartum Management
Vaginal delivery is recommended for a woman with heart disease unless there are specific indications for cesarean birth. Minimize maternal pushing and use of the valsalva maneuver. (Blowing air through pinched nose, straining while defecating), limit prolonged labor.
Cardiac Disease: Postpartum Care
Even with no evidence of distress during pregnancy, labor, and childbirth, women may have cardiac decompensation during the postpartum period.
Women require close observation for signs of infection, hemorrhage, and thromboembolism.
Conditions can act together to precipitate postpartum heart failure in women with underlying heart disease.
Cardiomyopathy and pregnancy
Rare and often fatal; late pregnancy to 5 months post partum
No identifiable cause and no prior cardiac history
Signs and symptoms: dyspnea on exertion, basilar crackles, nocturnal cough, edema, weakness, chest pain, eart palpitations
40-50% have partial recovery with persistent CHF
Incomplete recovery of left ventricular function
Treatment with heparin, fluid restriction, vasodilators, dopamine agonists
Viral Infection : Cytomegalovirus
Member of the herpes group; widespread and infects most humans through blood and body fluids. No effective therapy available
Primary prevention – handwashing and good hygiene.
Can cause cranial abnormalities or growth restriction in infants, learning disabilities, hearing loss.
Genital herpes during pregnancy
-Complications rare; could cause spontaneous abortion or preterm labor.
-Neonatal herpes is uncommon but potentially devastating – skin or systemic
-Acyclovir given to mother during late pregnancy
If no genital lesions, can deliver vaginally
-C-section recommended when active lesions in genital area
UTI’s and pregnancy
E. coli, Klebsiella, Proteus
Ascending bacterial infection can result in cystitis or pyelonephritis in later pregnancy
Clean- catch urine specimen
Antibiotics
Teaching - wiping front to back, good hydration
HIV and pregnancy
-Prevention only way to control HIV; early identification important
-Maternal zidovudine (ZDV) therapy to reduce infant HIV infection – dependent on a number of factors
-Learning of HIV infection during pregnancy can be devastating
-Breastfeeding contraindicated in HIV positive women
-Antiretroviral drugs have improved the prognosis
-Early signs of HIV in newborn: enlargement of liver and spleen, lymphadenopathy, failure to thrive, thrush, chronic or recurrent diarrhea
-Prompt treatment of infant may slow progress of infection
Infections During Pregnancy: NonviralToxoplasmosis
Toxoplasmosis is a protozoan infection transmitted through raw and undercooked meat, through contact with infected cat feces or soil. Transmitted across placental barrier to fetus from mother. Infants may be asymptomatic at birth, but others have serious effects: low birth weight, enlarged liver and spleen, jaundice, anemia or coagulation disorders.
NonviralToxoplasmosis management/prevention
-Cook meat thoroughly
-Avoid touching mucous membranes of mouth and eyes while handling raw meat
-Wash all surfaces that come in contact with uncooked meat
-Wash hands thoroughly
-Avoid uncooked eggs and unpasteurized mile
-Wash fruits and vegetables
-Avoid contact with potentially contaminated materials
-Pregnant women should avoid changing cat litter boxes
-Treatment with sulfonamides or combination drug
